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Glossary

Fractures of the distal metaphysis can be transverse, oblique, or
comminuted.
Always confirm the fracture configuration with views in both planes.
Irreducible and unstable fractures require ORIF.
Other indications for ORIF are open fractures, or soft-tissue lacerations.

Identifying malrotation

At this stage, after provisional fixation, it is advisable to check the
alignment and rotational correction by moving the finger through a range of
motion.
Rotational alignment can only be judged with the fingers in a degree of
flexion, and never in full extension. Malrotation may manifest itself by
overlap of the flexed finger over its neighbor. Subtle rotational malalignments
can often be judged by tilting of the leading edge of the fingernail, when the
fingers are viewed end-on.
If the patient is conscious and the regional anesthesia still allows active
movement, the patient can be asked to extend and flex the finger.
Any malrotation is corrected by direct manipulation and later fixed.

Planning plate position

It is wise to use magnifying loupes for this step.
Plan the blade position as dorsal as possible, in order not to injure the
collateral ligament.
Make sure that the plate will be perfectly aligned with the long axis of the
proximal phalanx in the lateral view.

Corresponding flare

The minicondylar blade plates are available in two forms. One fits on the
ulnar aspect of the bone, and the other on the radial aspect. It is a common
mistake to choose the wrong one. The correct implant will have the blade dorsal
and the distal screw hole palmar.

Trim the plate

Adapt the plate length to fit the length of the proximal phalanx. Avoid
sharp edges which may be injurious to the tendons. There should be at least 3
plate holes proximal of the fracture available for fixation in the diaphysis.
At least two screws need to be inserted into the diaphysis.

Prepare the bladeMeasure the length of the drill hole.
Cut the blade to the determined length, so that it just fills the drill
hole.

Pearl: Cut the blade transversely

If you cut the blade on the flat, it will compress and widen very slightly
as it is cut. This makes its maximal width very slightly larger than 1.5 mm. It
may not fit in the 1.5 mm hole that you have drilled.
Therefore, cut the blade on edge (to deform it through its narrower dimension)
to the correct length. The resultant tip is somewhat arrow-shaped.

Pitfall: avoid dangerous edge

If you are using a dedicated minicondylar plate cutter which trims the plate
by a shearing action, be very careful not to create a sharp dorsal edge that
will endanger the extensor apparatus. Correct cutting will produce the sharp
edge on the bone side of the plate.

Pitfall: Protrusion of the blade

Avoid protrusion of the blade through the opposite cortex, as friction
during movement and eventual ligament injury may result.
Due to the fact that the phalanx is wider on the palmar side that on the dorsal
side, an AP or PA x-ray view may suggest that the blade is fully contained
within the bone, whereas in transverse section, it actually protrudes.

Drill neutral proximal hole

Rotation check

At this stage, after provisional fixation, it is advisable to check the
alignment and rotational correction by moving the finger through a range of
motion.
If the patient is conscious and the regional anesthesia still allows active
movement, the patient can be asked to extend and flex the fingers.